Senior Coordinator, Complaint & Appeals - Remote

CVS Health•Work At Home-West Virginia, WV

1d•Remote

About The Position

This position is for a Dental Senior. Prepares information and reports needed to address matters regarding complaints, appeals, and grievances. Carries out policies, procedures, and programs to ensure compliance with federal and/or state regulations.

Requirements

Minimum Requirements - Preferred 3-5 years of experience in a Customer Service role.
Experience in reading or researching benefit language
Medicare and/or Medicaid knowledge
At least 5 years of experience that includes but is not limited to claim platforms, products, and benefits; patient management; product or contract drafting; compliance and regulatory analysis; special investigations; provider relations; customer service or audit experience
Ability to work in fast paced environment
Excellent verbal and written communication skills.
Excellent organizational skills to handle high inventory which aids in meeting or exceeding metrics.
Solution driven and can handle complex issues with accuracy.
Availability to work alternating weekends for oversight of analysts on alternate schedule.
High school diploma or equivalent required.

Responsibilities

Conducts team reviews, interpretations, and appeals filed by patients, escalating more complex issues and concerns to management for review and follow-up.
Ensures adherence to regulatory requirements, conducts internal audits, and addresses any identified compliance issues with the Complaint and Appeals policies and procedures.
Facilitates in-depth reviews of decisions and case files to determine if there are errors or anomalies in the application of law or evidence.
Oversees the drafting and progression of appeal decision letters, conducting detailed follow-up for timely and thorough follow-up and resolution.
Monitors key performance indicators (KPIs) and metrics to evaluate the effectiveness and efficiency of the appeals and grievances process.
Ensures all front-line associates promptly and accurately respond to all patient billing questions and concerns.
Facilitates and provides educational materials, training programs, and presentations to enhance understanding of the appeals and grievances process.
Coaches and mentors other colleagues in techniques, processes, and responsibilities for effectively handling member complaints and appeals.
Trains junior-level staff to promote the development of departmental capabilities.